Facial asymmetry of the hard and soft tissues in skeletal Class I, II, and III patients

To investigate and compare the facial asymmetry (hard and soft tissues) among skeletal Class I, II, and III patients. A total of 221 subjects, including skeletal Class I (n = 80), skeletal Class II (n = 75), and skeletal Class III (n = 66), were included in the study. CBCT, 22 skeletal landmarks, and 10 soft tissue landmarks were used for the measurements and the asymmetry index was calculated to assess the facial asymmetry. Statistical analyses included one-way ANOVA, Kruskal–Wallis test, and Spearman correlation analysis. The skeletal Class III patients presented greater asymmetry than Class II patients for 10 hard tissue landmarks and 3 soft tissue landmarks (p < 0.05). High correlation of asymmetry was found between four soft tissue landmarks and their corresponding skeletal landmarks (rs ≥ 0.71), as well as Me and ANS (r > 0.86). The ANS and Me in 21.3% patients deviated to contralateral sides. The skeletal Class III patients had more facial asymmetry than the Class II patients. Soft tissues showed similar asymmetry as the underlying hard tissues rather than a compensation of the hard tissue asymmetry. The inconsistency in the deviation of Me and ANS may exacerbate facial asymmetry.


Facial asymmetry assessment
The reference planes (Fig. 1), hard tissue landmarks (Fig. 2), and soft tissue landmarks (Fig. 3) used in this study were based on the literature 18,26,[30][31][32] and summarized in Table 1.The method of generating midsagittal plane (MSP) was adopted from the literature 17 .Three anatomic points (sella, nasion, and basion) were defined on the cranial base, and the plane that passed through these designated points was defined as MSP.The axial plane passed through the sella point and the nasion point and was perpendicular to MSP; the coronal plane passed through the cranial base point and was perpendicular to MSP and the axial plane respectively (Fig. 1).
The Asymmetry Index (AI) was used to evaluate facial asymmetry based on the literature 30 the formula was: (Rdx − Ldx) 2 + Rdy − Ldy 2 + (Rdz − Ldz) 2 , where the R indicates right and L indicates left.The distances between each anatomical point and the three planes were measured with the Mimics 19.0 software and defined as dx, dy, and dz.Variable dx represents distance from anatomical point to MSP, dy represents distance from anatomical point to the coronal plane, and dz represents distance from anatomical point to the axial plane.For solitary paramedial points, dx was used to summarize AI index; for bilateral landmarks, the aforementioned formula was used to calculate AI index.The intra-rater reliability analysis was performed using 10% of the total samples randomly at one-month intervals.The intraclass correlation coefficient (ICC) was 0.90-0.95,indicating an excellent repeatability.

Statistical analysis
SPSS software (version 18.0; IBM, Armonk, NY) was used for statistical analysis.The Pearson's chi-square test, One-way ANOVA, and Kruskal-Wallis test were used for statistical comparisons; the Spearman correlation analysis was used to analyze the correlation between the soft tissues and the underlying hard tissues, as well as the facial asymmetry index of Me and ANS point.

Results
Characteristics of the subjects (gender and age) were similar among the three groups (Table 2).
The asymmetry index (AI) values of hard tissues (Table 3) and soft tissues (Table 4) were greater than 0 for all participants.The AI values of hard tissue landmarks (LMC, A, ANS, B, Gn, Me, and Pg) (Table 3) and soft tissue landmark (Li) (Table 4) had significant differences among the skeletal Class I, II, and III groups; these landmarks were generally at, or close to, the midsagittal plane.The hard tissue landmarks Cor and L1I (Table 3) and soft tissue markers Ala and Ch (Table 4) had significant difference between the skeletal Class II and Class III groups.
The skeletal Class III group had the greatest facial asymmetry for most hard tissue and some soft tissue landmarks (i.e.A, ANS, B, PNS, Gn, Me, Pg, U1l, L1l, Ala, Ch, Ls, Li, Sn, Cor, Lmc, and U6O), followed by the skeletal Class I, and skeletal Class II (Tables 3 and 4, Fig. 4); and these landmarks were at, or close to, the midsagittal plane.The AI values of soft and hard tissue landmarks generally increased from the top to the bottom of the face, including ANS, A, U1L, L1I, B, Pg, Gn, Me, En, ZyS, Ala, Ch, GoS, Ls, Li (Tables 3 and 4, Fig. 4).
There were positive correlations (r s = 0.71-0.87)between six soft tissue landmarks (Ch, Sn, Ls, Li, GoS and ZyS) and their corresponding hard tissue landmarks (LMC, A, U1L, L1I, Go and Zy) (P < 0.01 for all) (Table 5).A high AI value correlation was also found between the hard tissue landmark ANS and Me (Fig. 5), however 21.3% of patients had ANS and ME point deviation direction inconsistency (Table 6 and Fig. 6).There was no significant difference of the deviation direction of these two points between male and female subjects (Table 6).

Discussion
A number of clinical studies have evaluated facial asymmetry from the aspects of hard tissues 8,10,18,22,23 soft tissues 26,33 and both 9,17,25 .The findings of this study suggest that the skeletal Class II patients showed relatively more facial symmetry than skeletal Class III patients and the soft tissues showed a similar asymmetry as the underlying hard tissues.Among all landmarks measured in the present study, 12 hard tissue landmarks and 6 soft tissue landmarks showed that the skeletal Class III asymmetry index was the largest and the skeletal Class II asymmetry index was the smallest, but there was no statistical significance between Class I and III, nor between Class I and II.This is consistent with previous studies 18,22 .A large population based study in Japan (n = 1800) found that the patients showing no chin deviation was 36.9%,41.4%, and 33.6% in skeletal Class I, II and III malocclusions, respectively 5 .It has been found that skeletal Class II patients are likely to have relatively less mandibular growth than skeletal Class III patients who generally exhibit greater mandibular growth and may be more likely to be affected by postnatal environmental influence during the relatively longer jaw growth period 34 .A number of studies have found that Class III patients had more facial asymmetry 12,17,23 , which may be due to the environmental influences and habitual chewing on one side 5 .
It has been found that the chin deviation to the left (70-90%) was more prevalent than the deviation to the right 19,22 .In the current study, however, no significant difference of the chin (ME point) deviation was found between the left and right.This may be due to the differences in study population and evaluation methods.
The median-sagittal plane (MSP) is often used as a reference for the mirroring and segmentation processes to assess facial symmetry and asymmetry.The current study adopted the method described in the literature 17 .A number of methods can be used to generate the midplane [35][36][37][38] .The cephalometric landmark based midplane is the traditional approach; it is relatively easy but sometimes the unpaired landmarks are not exactly in the middle of the face, resulting in an unreliable MSP 39 .Morphometric measurement has been reported to define the true MSP, but very few software programs have this function 36 .A study compared two digital methods (interactive closest point algorithm (ICP) and Procrustes analysis (PA)) to determine the median sagittal plane.Results showed that ICP and PA were similar for subjects with no obvious facial asymmetry, but for the subjects with obvious facial asymmetry, it remained unclear which one computes the ideal MSP 37 .To date, the best approach to define the true MSP is still contested in the literature.
Although facial asymmetries are mostly perceived on horizontal and transversal planes by patients and observers, it can occur in all three planes of space 40 .The current study analyzed the facial asymmetry in three dimensions.In the literature, facial asymmetry has been evaluated morphologically and classified into different categories [41][42][43][44] .In addition to morphological asymmetry, there can be spatial asymmetry.It has been found that  www.nature.com/scientificreports/some subjects presented no difference in the size and length between the right and left mandibular sides but still had Me point and lower apical base midline deviated to one side.This type of asymmetry has also been described as functional asymmetry 44 , and was suggested to be intercepted at an early stage because the condyle and fossa could adapt easily to the deviated mandibular position.It is clinically important to qualify and quantify the dental, skeletal, soft tissue, and functional asymmetry for the accurate diagnosis and appropriate treatment.The external (soft tissues) and internal (hard tissues) appearances of facial asymmetry are both clinically important, and they are often correlated.It has been found that there was a high covariance between the soft tissues and the underlying hard tissues 25 .A CBCT study evaluated the right and left difference of facial soft tissue landmarks in subjects with normal occlusion and found that the bilateral landmarks presented greater asymmetry and higher variability than the midline landmarks 26 .It is interesting to note that in the current study, although there was a high correlation between the asymmetry index of ANS and ME points, these two landmarks deviated to different sides in about 20% patients.There is evidence showing that the deviations at the tip of the nose were always rated as more asymmetric than the same deviations of the chin; the nasal tip shift left-sided and chin shift right-sided were judged as significantly more asymmetric 45 .Whether the deviation direction of ANS and ME exacerbates or alleviates facial asymmetry still requires further studies.
There are limitations in the present study.The reproducibility of soft tissue landmarks is generally low 46 .The eight soft tissue landmarks used in the current study were relatively easy to locate, however, most of them are at, or close to, the midface, which may not be adequate to reflect whole facial asymmetry.Future studies using morphometric methodology, 3D stereophotogrammetry, and dynamic motion capture may provide a better understanding of the facial asymmetry, by taking into consideration of the shape, size, and volume of the facial soft and hard structures.

Conclusions
All patients presented facial asymmetry to a different degree.Skeletal Class III subjects presented greater facial asymmetry than skeletal Class II patients.Midface soft tissues showed a similar asymmetry as the underlying hard tissues rather than a compensation of the hard tissue asymmetry.The inconsistency in the deviation of Me and ANS may exacerbate facial asymmetry.

Figure 1 .
Figure 1.Schematic diagram of the 3D reference plane viewed from different positions (a) Right side view (b) Front view (c) Left side view.

Figure 4 . 4 Table 5 .
Figure 4. Comparison of the asymmetry index (AI) among the Class I, II, and III.(a) The hard tissue asymmetry: Class III > I > II.(b) The soft tissue asymmetry: Class III > I > II.*Statistical difference between the two groups, P < 0.05.**Statistical difference among the three groups, P < 0.05.

Figure 6 .
Figure 6.Deviation direction of ANS and Me.(a) Deviation directions consistent (b) ANS and Me at the MSP (c) Deviation directions inconsistent.

Table 1 .
Landmarks and reference planes used in the study.
the Sella point (S), the Nasion point (N), the Basion point (Ba) Horizontal Plane Horizontal Plane passing through the Sella point (S), the Nasion point (N) and perpendicular to the midsagittal plane (MSP) Coronal Plane Coronal Plane passing through the base of the Basion point (Ba) and perpendicular to the midsagittal plane (MSP) and the horizontal plane, respectively

Table 2 .
Characteristics of the sample.

Table 3 .
Comparison of hard tissue facial asymmetry index among the skeletal Class I, II and III.Data represent median (interquartile range).*P < 0.05; **P < 0.01.a Statistical difference between skeletal Class I and II (P < 0.05).b Statistical difference between skeletal Class II and III (P < 0.05).Bold font indicates statistical difference among the three groups (P < 0.05).

Table 4 .
Comparison of soft tissue facial asymmetry index among the Skeletal Class I, II and III participants.Data represent median (interquartile range).

Table 6 .
No statistical significant difference of ANS, Me, and deviation direction between the male and female participants (n, %).